A recent study by Abraham, et al., published in the March Journal of Studies on Alcohol and Drugs, finds that patients receiving treatment at publicly-funded programs have significantly less access to potentially life-saving substance use disorder (SUD) medications like buprenorphine, disfulfiram, acamprosate, and naltrexone. Buried in the report, however, is the shocking statistic that a full 56.4% of the programs (publicly- or privately-funded) prescribed no medications whatsoever. Clearly, there are a whole lot of consumers not being informed of their full array of choices when it comes to managing their treatment.
The study analyzed nearly 600 treatment programs throughout the country - data originally part of the National Treatment Center Study – and looked for differences in physician access and SUD medication access. The authors found that 10.9% offered access to one medication, while 32.7% offered more than one medication. Fewer than 5% of programs offered access to all of the above medications.
The authors note that nearly 2/3 of all specialty SUD treatment programs in the US are publicly funded, relying on government block grants and state contracts for the money needed to provide treatment, while private funding tends to come from private insurance and self-paying patients.
When divided into publicly-funded and privately-funded categories, private programs were almost 15% more likely to have a physician on-staff and nearly 10% more likely to employ master’s-level counselors. And while publicly-funded treatment programs were almost 14% less likely to prescribe buprenorphine, only 32.5% of all programs offered the medication. Only 20.6% of programs offered disulfiram, 27% offered tablet naltrexone, 27% offered acamprosate, and a slim 13.1% of programs offered injectable naltrexone.
Among other findings, programs with a more professional workforce were positively correlated with the number of SUD medications offered, and programs with a physician on staff were more likely to offer higher numbers of SUD medications than programs with no access to physicians.
These findings beg the question: why are evidence-based practices so rare and why is this tolerated in addiction treatment but not in other professional treatments? (What if over half of American cardiologists prescribed no medications to their patients?) Sure, public programs offer fewer scientifically-supported therapies – but even people who are spending a fortune of their own money are often getting poor care. When patients are not informed of the full array of treatment options, the lack of informed consent becomes an ethical – and likely legal – issue.
For alcoholism, the medications available - disfulfiram, acamprosate, and naltrexone - have low-to-moderate efficacy. AFAIK, the NNT is around 9 or less for any of the three. Other drugs touted around the Internet are not well-studied.
ReplyDeleteGiven the above, what should a clinician do vis-a-vis medications?
Fair point. While the NNT I have seen are closer to 7 and better, it is still by no means a magic bullet. However, these medications are safe, have been shown to work in large and well-organized studies, and are usually affordable. As clinicians, the most important point is that our clients need to know that there are medications available to them, which might very well help them in their recovery. We cannot hold this information from them because of our biases - we show them the available data and allow them to make an informed choice.
DeleteWell, give us some idea:
ReplyDeleteWhat does your program prescribe for a chronic alcohol dependent? Is there any role for baclofen or topiramate?
"Campral is the med most likely to be prescribed by general psychiatrists because it was marketed to them. In the US, physicians tend to rely on pharmaceutical representatives too much, as opposed to reading the scientific literature themselves. Unfortunately, I don't think Campral works."
ReplyDeleteMany of the people I encounter, particularly courts and those in the criminal justice system, view medication assisted treatment as some type of substance substitution. Some Methadone clinics make the problem worse by over medicating clients and making little effort towards eventual reduction of the medication. Also, those with experience with NA/AA approaches have attached such stigma to any type of medication they don't really consider those in MAT as "clean and sober". Finally, there is a cost associated with prescribing physicians and medication in general. While injectable Naltrexone would be perfect for many clients, most of them can barely afford rent and certainly can't pay the several hundred dollars a month some of these medications cost. Hopefully these problems can be solved in the coming years so that more clients can get the best treatment available.
ReplyDeleteThank you for expressing these thoughts, Daniel. Over the past two decades I've watched someone go from insurance-covered treatment (in the 'reputable' hospitals, individual therapy, etc.) to the world of street programs available to our homeless population. There is no medication offered here. Often there is no psychologist, much less a psychiatrist, even remotely connected to these county, church, or city programs. The 'director' takes everyone's general assistance checks. AA/NA meetings are mandatory (they're free; going without medication is of course also free). There may or may not be a place to live during the 'treatment.' If there is a place to live, there are drug dealers outside. If there is no place to live, you must line up to find a bed in a shelter every evening and, without any medication or therapy (only group sessions run by people barely clean themselves), get it together to go back the next day. Oh, I forgot--it's unmanageable on your own.
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